Provider Demographics
NPI:1780775486
Name:HAMILTON, BENITA NANNETTE (PA-C)
Entity type:Individual
Prefix:
First Name:BENITA
Middle Name:NANNETTE
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4764 SPRUCE WAY SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH FULTON
Mailing Address - State:GA
Mailing Address - Zip Code:30331-7540
Mailing Address - Country:US
Mailing Address - Phone:845-551-4229
Mailing Address - Fax:
Practice Address - Street 1:500 NATHAN DEAN BLVD STE 105
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-4911
Practice Address - Country:US
Practice Address - Phone:470-624-6792
Practice Address - Fax:470-202-1026
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005769-1363A00000X
GA12130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355931Medicaid
NY331886Medicare Oscar/Certification